Minyang Mao, M.D.

Minyang Mao, M.D. San Francisco Bay Area Psychiatrist: Caring, Comprehensive, Confidential. Core Values of my practice:
http://minyangmaomd.com/?page_id=1162

U.S. Private Health Insurance examined Part 2: The Good, the Bad, and the UglyMy practice was in-network for multiple pr...
02/20/2025

U.S. Private Health Insurance examined Part 2: The Good, the Bad, and the Ugly

My practice was in-network for multiple private health insurance companies for many years. Gradually, I grew weary of the games insurance companies play with doctors and patients in order to increase their profits, so I became “out-of-network” for more and more insurance companies. My decision many years ago to drop my last insurance plan and become completely out-of-network freed me to focus my time and energy on providing the best care for my patients rather than jumping through hoops for insurance companies. However, me becoming out-of-network left in-network doctors and some patients in a worse position.

Let me explain how:
Let’s say there are 10 in-network doctors caring for 1,000 patients. This means 1 doctor cares for 100 patients. Let’s say one of those doctors decides to go "out-of-network". This has numerous downstream effects - The Good, the Bad, and the Ugly:

The Good: 1 doctor is now out-of-network, and they charge patients directly what they believe to be a fair fee for their services. 50 patients have the financial means to pay for out-of-network care. The 1 out-of-network doctor is now taking care of 50 patients instead of 100 patients, and can afford to spend more time with each patient and still pay the bills because they are being more fairly reimbursed for their services. This results in both happier patients and a happier doctor.

The Bad: The other 950 patients continue to see in-network providers because they're already paying so much for health insurance, and paying extra to see an out-of-network doctor is either not financially feasible or seems to be an unnecessary expense. The 9 doctors who are still in-network now have to take care of 950 patients. Instead of taking care of 100 patients each, these in-network doctors now need to take care of 106 patients each. The amount of work has increased, but there are still only so many hours in a clinic day. Each in-network doctor now has to squeeze in 6 extra patients into their workday. This results in shorter appointments that force the doctors to rush to accomplish the same amount of work in shorter periods of time. Patients feel rushed and unheard by their doctors. In-network doctors are forced to practice medicine in ways that make them unhappy.

The Ugly: Because of the worsening work conditions, another in-network doctor decides to become out-of-network. Another 50 patients follow them and seek out-of-network care. The remaining 8 in-network doctors now are responsible for 900 patients. Each in-network doctor is now are taking care of 113 patients instead of 106. Even shorter appointments and even longer workdays result. In-network doctors and their patients become increasingly unhappy.

Conclusion:
The U.S. private health insurance system is broken and has continued to degrade year after year. By jumping ship and becoming out-of-network, I have only worsened the problem for in-network doctors and the patients they care for. I do not know how to fix the system, but I hope that sharing my observations will help clarify the problems so that we can move towards better solutions.

*Disclaimer: I am not a health insurance or economics expert. My analysis is based on my personal observations as both a patient and doctor receiving and providing healthcare in the U.S.

U.S. Private Health Insurance Examined Part 1: Squeezing Both Ends from the MiddleHow in the world do U.S. private healt...
02/15/2025

U.S. Private Health Insurance Examined Part 1: Squeezing Both Ends from the Middle

How in the world do U.S. private health insurance companies keep earning more and more profit? Why is it that patients pay more and more for healthcare, but in-network doctors get paid less and less for their services?

The answer lies in the middle: between patients and doctors lie the middlemen. In the U.S., private health insurance serves as a middleman between patients and doctors. In order to increase their profits, health insurance companies must extract more and more money from BOTH doctors and patients: Squeezing both ends from the middle.

Let me explain how:
To help understand this complex situation, let’s examine the following scenario:

Patients pay $1100 in premiums
Doctors get paid $1000 (91% of premiums)
Insurance gets paid $100 (9% of premiums)

Profit tactic 1: Charge patients more
"Let's charge patients $1300. We're required by the Affordable Care Act’s Medical Loss Ratio to spend at least 80% of the premiums we collect from patients on patient care and quality improvement, so I guess we'll pay the doctors a little more too."

Result:
Patients pay $1300 in premiums
Doctors get paid $1105 (85% of premiums)
Insurance gets paid $195 (15% of premiums)

Profit tactic 2: Make it harder for doctors to get paid
"How do we extract more money from the doctor side of the equation? I know, we'll just make it more difficult for doctors to get paid for 4% of the care they provide - we'll lock reimbursement for 4% of care behind pre-authorization requirements, documentation requests, and phone calls for "peer review". By the time doctors get through unlocking the payment for that 4% of care, they'll have spent $50 of unpaid time to get $39. Over time they'll just stop fighting to get the unpaid 4% of services because it doesn't make sense to spend $50 to earn $39."

Result:
Patients pay $1300 in premiums
Doctors get paid $1066 (82% of premiums)
Insurance gets paid $234 (18% of premiums)

Profit tactic 3: Make it harder for patients to get care
"How do we extract more money from the consumer side of the equation? I know, we'll make it more difficult for patients to get the care they seek by limiting where, when, and from whom they can get healthcare, and require them to get pre-authorization, provide documentation, and call us to appeal their cases. This way at least 2% of the time patients will find the health problems not urgent or severe enough to put in all that work to get care."

Result:
Consumers pay $1300 in premiums
Providers get paid $1040 (80% of premiums)
Middlemen get paid $260 (20% of premiums)

Profit tactic 4:
Health insurance companies buy up physician practices so that now insurance companies receive and keep both the 20% AND the 80%. They can then pay their physician employees 70% of what the consumer pays and pocket the other 10% as a “provider”, bringing their take to 30% of the consumer cost of healthcare without breaking the Medical Loss Ratio Rule of spending 80% on patient care.

Profit tactic 5:
Health Insurance companies can game the Medical Loss Ratio by lobbying to have some parts of their administrative expenses (usually counted in the 20% portion) to be counted as patient care and quality improvement (counted in the 80% portion). At the end of the day, this paper shuffling allows them to circumvent the 20% limit and thus keep more money as profit.

Profit Tactic 6:
Some health insurance plans (generally PPOs) reimburse a percentage for out-of-network provider care. One way for insurance companies to wring more profit out of patients is to reimburse patients less for out-of-network care. Instead of paying patients $100 out of $200 for an out-of-network visit, they decide to pay $50 out of $200. Another $50 profit for the health insurance companies.

Conclusion:
We have to somehow force health insurance companies to stop squeezing both doctors and patients in their efforts to make more and more money. I don't know how to make that happen, but I am watching the problem get worse year after year from both the patient end and the doctor end.

*Disclaimer: I am not a health insurance or economics expert. My analysis is based on my personal observations as both a patient and doctor receiving and providing healthcare in the U.S.

https://www.nytimes.com/2024/05/09/well/mind/loneliness-brain-dementia-isolation.html?smid=nytcore-ios-share&referringSo...
05/14/2024

https://www.nytimes.com/2024/05/09/well/mind/loneliness-brain-dementia-isolation.html?smid=nytcore-ios-share&referringSource=articleShare

Making new friends and "addressing a person’s attitudes and thought patterns about social interactions through cognitive behavioral therapy" can be ways to combat the loneliness epidemic that our nation is facing.

Feeling chronically disconnected from others can affect the brain’s structure and function, and it raises the risk for neurodegenerative diseases.

https://time.com/6371479/mental-health-resolutions-2024/One particularly useful tidbit is the concept of "Core Four" act...
01/16/2024

https://time.com/6371479/mental-health-resolutions-2024/

One particularly useful tidbit is the concept of "Core Four" activities targeting each of these each week: 1) fun (pleasure) 2) skill (mastery) 3) social (connection) 4) exercise (physical)

Among them: rethink social-media use, reconnect with a long lost friend, and stop ruminating about work.

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